Prescription and Over-the-Counter Medications Tool Kit ... - Home

Hum-Res-4
Rev. 12/94
Los Angeles County Metropolitan Transportation Authority
Medication Evaluation Form
Reference: Alcohol and Drug Abuse policy section 4.6.1 - An employee must notify his/her department head
or division manager when taking any medication (whether prescription or over-the-counter) which may
interfere with the safe and effective performance of duties or operation of MTA equipment, or which carries a
warning label that indicates that mental functioning, motor skills, or judgment may be adversely affected.
Employee completes this section - all information is confidential.
Employee Name Badge/Employee No.
Job Title Division/Department
1. Name of medication.
2. How often and when is the medication taken?
3. When did you start taking this medication?
4. Describe any side effects.
Department head or division manager completes this section. Give a copy of this form to the employee after
discussion and agreement of the following medication restriction(s), if any. Call the Medical Desk at 2-7169, if you have
any questions regarding a medication restriction.
This medication is approved to take.
This medication has been determined to potentially impair an employee's performance. If the employee is in a
safety-sensitive position and/or drives MTA vehicles, then this medication should not be taken within eight (8) hours
of the employee reporting for duty, during the hours that the employee is subject to duty, or while the employee is
on duty. If the medication contains alcohol, the pre-duty abstinence is within four (4) hours of the employee
reporting for duty, during the hours that the employee is subject to duty, or while the employee is on duty.
The employee should contact his/her physician to discuss an alternate schedule to take this medication or obtain
another medication which will not impair his/her job performance or interfere with his/her work schedule.
We have discussed the above medication(s). The employee agrees to follow the above medical restriction(s), if any.
Employee Signature Date
Supervisor Signature Date
Original-Division/Department Medical File Copy-Employee